Better Broadband for Better Health Care


Here’s a question that we don’t often ask: which is the U.S. more likely to accomplish – getting everyone health insurance, or broadband?  Hint: it’s probably not what you think.

The health insurance part of it is often debated.  We passed ACA, but the number of uninsured stubbornly remains at nearly 30 million, almost 10% of the population.  Still, except for residents of those 12 states that have refused to pass Medicaid expansion, everyone in the country has at least access to public or private health insurance, with subsidies available to many. 

Broadband hasn’t been around as long a health insurance, but it has become an integral part of our society, as the pandemic proved (ever try remote work or learning without broadband, much less telehealth?).   Unfortunately, some 20 million households lack broadband; assuming an average household size of about 2.5, that’s some 50 million people, which is way more than the number of uninsured. 

Welcome to the digital divide.   

Everyone seems to agree increasing access to broadband is a good goal.  It’s part of President Biden’s proposed infrastructure plan, and even many Republicans support some funding towards the goal, as in a recent bipartisan proposal

We often think about the issue as being a rural problem, similar to the problem of electricity availability in rural areas before the Rural Electrification Act (1936).  It’s just hard, or at least expensive, to wire all those vast spaces, those farms and small communities that comprise much of America. 

The fact of the matter, though, is that of those 20 million households without broadband, some 15 million of them are urban households.  A higher percent of rural households may lack broadband, but, in terms of actual numbers of households lacking it, it is urban dwellers.  For the most part, broadband is available in their neighborhood; they just can’t afford it (or don’t see the need).  

But mostly we focus about the rural problem, for the wrong reasons.  Blair Levin, a Brookings fellow, told The New York Times:

From an economic and society perspective, the most important thing to do is to get online everybody who wants to be online.  From a political perspective, the biggest political capital is behind accelerating deployment where there is none, which means in rural areas.

The same article quoted testimony from Joi Chaney, senior vice president at The Urban League, before the House Appropriations Committee: “Our investments must not only solve for the deployment or availability gap.  They must also solve for the adoption gap, the utilization gap and the economic opportunity gap to truly achieve digital equity.”

As with health insurance, the problem is less access than it is affordability.  Josh Stager, senior counsel at the Open Technology Institute, emphasized:

Once the pandemic started, it became painfully obvious that internet connectivity is a utility, and it’s not just necessary to get through the pandemic but to get through modern life in America.  And the reality — that so many people are struggling with affording the service, not access — became undeniable.

Brookings calls it “digital poverty.”  Others point to “digital redlining,” which means you’re more likely to get fiberoptic or other types of faster connections if you live in a wealthy suburb or a gentrified urban neighborhood. 

We don’t allow these kinds of disparities for electricity, telephone service, or water, but we do for broadband — and for health care.  How very 1930’s of us. 

As Brookings put it:

Digital poverty is akin to an entire neighborhood with spotty electricity or unreliable water service. These are places where students struggle to engage with digital coursework and adults can’t check online job boards. Digital poverty is a tangible drag on economic prosperity.

There are some subsidies available for broadband, most notably the FCC’s Lifeline, which pays a maximum of $9.25 monthly. An Open Technology Institute analysis estimated the subsidies only cover 13% of the actual broadband costs, while even the FCC acknowledges that only 26% of eligible households participate. 

I guess we should stop complaining about ACA subsidies. 

Broadband reminds me of healthcare in another way: Americans pay way too much for way too little.  Our astronomical healthcare spending gets us only middling health care outcomes, but, by the same token, among OECD countries, only Mexico pays more for broadband.  Our broadband speeds rank us at best tenth in the world; it’s one thing to be behind urbanized countries like Singapore or Hong Kong, but France or Hungary? 

It’s all part of a pattern.  It is true that rural hospitals have been struggling, even closing, at alarming rates in recent years, but so-called safety net hospitals, usually in urban areas, have been hit hard as well.  It is true that many rural areas qualify as “food deserts,” but more urban residents live in them, and that affordability is as least as important as availability for food as well. 

Ezra Klein wrote recently:

This is the conversation about poverty that we don’t like to have: We discuss the poor as a pity or a blight, but we rarely admit that America’s high rate of poverty is a policy choice, and there are reasons we choose it over and over again.

Whether it is poverty, broadband, health care, food security, unemployment benefits, wage inequalities, or a number of other hot issues, the root of our problems usually lie not in poor personal choices but in policy choices – some with unintended consequences but many with foreseeable outcomes. 

ACA made a tactical choice to put more money into our existing structures, such as expanding Medicaid, and guaranteeing access to and subsidizing private insurance.  There simply weren’t the votes to make more dramatic changes (and still aren’t). 

We may be making a similar mistake with broadband.  We may choose to simply wire more areas that lack broadband, but without ensuring that more people have the ability, and see the need, to pay for it.  We should also be attacking our high cost of broadband and forcing improvements in our speeds.  As Brooking’s Tom Wheeler pointed out, “it is foolhardy for the government to spend public money for second class service.”  He urged that we “future-proof” broadband.

Even prior to the pandemic, some labeled broadband access as a public health issue.  Bauerly, et. Alia., called broadband access a “super-determinant” of health, and warned: “digitally isolated communities may risk worse health outcomes resulting from the effects of limited broadband access on educational and economic opportunities as well as access to high-quality health services.”

We can’t get the health care system, or health care outcomes, that we want unless we also “future-proof” broadband.   

Kim is a former emarketing exec at a major Blues plan, editor of the late & lamented Tincture.io, and now regular THCB contributor.